The Choice And Partnership Approach A Guideline for Letting Go · Planning for letting go with children, young people and their family/whānau should begin from the first contact.

The Choice And Partnership Approach

A Guidelinefor Letting Go

The Choice and Partnership Approach (CAPA) The Choice and Partnership Approach (CAPA) was developed by Ann York and Steve Kingsbury in the United Kingdom. CAPA is a collaborative service improvement model offering Choices to young people and their families/whānau in their dealings with mental health and addiction services. CAPA aims to maximise the effectiveness of practitioner skills and administration processes to make every step add value for the service user. CAPA is flexible, can be tailored to fit individual services and encourages early face-to-face contact, family/whānau involvement and client self-determination. CAPA is about empowering children and young people and their family/whānau to access their own resources and the resources within their communities, so they can move forward with their lives. Part of this is not to assume they need services and if they do, to focus on the time that they will no longer need Infant, Child and Adolescent Mental Health Services (ICAMHS). The CAPA activity of ‘letting go’ refers to the case closing and ending of an episode of care, where the young person and their family/whānau transitions out of the service. The ability to let go is important in helping children and young people and their family/whānau to regain control of their lives; and assists teams to achieve a smooth flow through their services. Letting go should not be thought of as an ending, but a beginning.

The Letting Go processThis guideline aims to enhance the understanding of the letting go process within the CAPA framework. The guideline has been developed to support new clinicians, clinicians who are new to CAPA, and teams looking to have a consistent CAPA approach to care. Having a systematic approach to letting go and understanding the CAPA service model and all its elements is essential in assisting services to meet the needs of children, young people and their families/whānau. Using a guideline encourages a stance of continuous clinical practice improvement, and assists teams to extend capacity and meet service demand.

Further information can be found on the CAPA website: www.capa.co.uk and Werry Workforce Whāraurau website: www.werryworkforce.org/CAPA

1

Letting go The process of letting go occurs when ending a brief episode of care; transitioning a child or young person to another service; or the letting go of a child or young person who has ongoing issues. For many, letting go is cause for celebration; where the process is viewed as a positive growth experience supporting the independence of the child, young person and their family/whānau. For others, the ending of the therapeutic relationship can be an incredibly anxious time, as the letting go process can feel complex and create concerns for the child or young person, family/whānau and clinician.

As children and young people grow and develop, and families/whānau reach different stages and transitions, problems change and new issues can arise. Outcomes in ICAMHS can sometimes feel unclear when a child or young person experiences many issues and shares these with the clinician; clinicians may be left feeling there is always more they could work on. It is important for clinicians not to assume the need for ICAMHS involvement in every referral, or assume that the child, young person, and family/whānau won’t have the resources to move forward without ICAMHS support. Where a child, young person and their family/whānau does require ICAMH service input, there should be an immediate focus on the time when they will no longer require this level of service delivery, what this looks like and how this could be achieved within a specific timeframe. Individuals and teams quite often have strong feelings about what the work of secondary level ICAMH service delivery includes, and this can affect how they think about letting go.

Clinicians must therefore have a good understanding of the letting go process, the complexities and how best to create partnership pathways that support this process.

2

Letting go is one of the 7 Helpful Habits for which there are 3 activity items:

• Managing variation in closing case-files

• Using care plans

• Having a systematic approach to long-term problems

In ICAMHS the way we support the transition of children, young people and family/whānau out of ICAMHS and close files (letting go) is often well described in terms of administrative processes but poorly explained clinically. We tend to have well thought out processes to get into services, but how do we let people out? There are numerous factors that influence the ease and success of letting go and the duration of treatment. These include:

• The level of engagement and trust between the child/young person, family/whānau and clinician

• The type of treatment (a brief intervention or long term psychodynamic therapy)

• The focus on agreed goals and associated outcomes (the greater the focus and review process, the increased likelihood of positive outcomes)

• Clarity regarding the endpoint of an episode of care (as examples; symptoms resolve and menstruation returns in anorexia nervosa; or the service model is a brief intervention approach and the session numbers are fixed)

• The departure of the Partnership clinician (key worker) (often the child/young person and their family/whānau won’t want to continue on with another clinician)

• The clinician having protected time for administration, supervision and multidisciplinary discussions within clinicians’ job plans (all support focused service-delivery)

The factors that support Choice and Partnership for children, young people and family/whānau within a process of intentional contact with the service such as ‘letting go’ will inevitably lead to good outcomes for service users and an efficient use of resources.

3

Difficulties in transitioning, closing case files and letting go While some children, young people, family/whānau and clinicians will be better positioned to end the service contact than others, there are recurrent themes identified that explain why letting go remains a challenge. Some of the factors relate to factors identified by clinicians and services, and some relate to beliefs held by service users. The range of factors include:

• A culture of inter-dependence created both between the child, young person, family and the clinician, and the clinician and the family/whānau

• A lack of perceived continuing community support

• Concerns regarding ongoing risk and responsibility

• Long waits to re-enter services

• External pressures to keep case files open

Often there are a combination of these factors at play and these challenges are discussed further in this section.

Fears and concerns about going it alone

Some children, young people and family/whānau can experience concerns regarding their ability to manage without the support of ICAMHS. These feelings can be particularly strong for children, young people and family/whānau who have been with ICAMHS for a long time. Partnership clinicians (key workers) can sometimes be seen as a security blanket. Clinicians may also have to navigate family/whānau concerns about their own ability to manage after letting go; these concerns are often compounded if the child or young person still exhibits concerning behaviours. Negotiating conflicting views on readiness to let go can present challenges and clinicians can be left feeling like they are the only source of support. This can contribute to clinicians resisting letting go even when it is no longer clinically beneficial.

4

Unrealistic expectations

Another challenge in letting go involves unrealistic expectations; the weight of expectation on ICAMHS to ‘fix’ a child or young person’s problems, as well as pressure to continue treatment when a child or young person does not seem to be as well as hoped. ICAMHS often operate within an external narrative that every child or young person who requires help will achieve an optimal level of wellbeing during their contact with the service. Clinicians can be left feeling pressured to continue seeing a child or young person when successful treatment outcomes or more accurately, assumptions around what successful treatment outcomes should look like, are not being achieved. Long waiting lists can also create challenges regarding expectations. The longer families/whānau wait to enter a service and/or Partnership, the greater the expectation can be. This can lead to clinicians feeling obliged to attempt setting potentially unrealistic hopes and goals in the absence of realistic time based goals from the beginning of treatment.

When improvement is less than desired

Clinicians often hold strong beliefs about their role and what the work of a mental health service is. Although well-intentioned, clinicians may have feelings of perfectionism and omnipotence (the idea that they can and will solve their clients’ problems). This may lead to an overestimation of what is possible in treatment, influencing the letting go progress even where there is little demonstrable improvement being made.

Concerns regarding a lack of other sources of support

Letting go can feel particularly challenging when other sources of support are not available or easily accessible within the community.

Concerns and beliefs regarding limited skill, capacity and accessibility of other services across sectors can contribute to family/whānau and clinicians’ unwillingness to let go. Sometimes in these circumstances, clinicians may feel it is necessary to play a supporting role instead of one which provides specific treatments. Holding on to a child or young person and their family/whānau longer than necessary creates additional dependency on the ICAMHS environment, while also reducing access for other families/whānau to enter the service.

5

Concerns regarding ongoing risks

Ending treatment with a child/young person where risk remains, can create additional challenges to letting go. Concerns can relate to the safety and wellbeing of the child or young person, but also to professional liability concerns, a ‘the buck stops here’ mind-set. When clinicians identify ongoing risks, they may continue to see the child or young person for longer than clinical judgement might otherwise recommend ‘just in case’ or try other interventions unlikely to work to demonstrate that all avenues have been exhausted.

Long waiting lists

Long waiting times to re-enter ICAMHS can contribute to a reluctance in letting go. Children, young people and their family/whānau may be especially reluctant to let go if they initially experienced delays in accessing ICAMHS support. These concerns can sometimes then spill over impacting on the clinician’s decision making about letting go. Long re-entry times back into ICAMHS can also create anxiety for the clinician who has ongoing concerns regarding the level of risk associated with a particular child or young person, should their mental health deteriorate in the future.

Conflicting views about the role of treatment

Conflicting views across services and agencies about the right time to close case files can also contribute to clinicians experiencing difficulties with letting go; services and clinicians can have differing views about how to measure progress, and what positive outcomes look like. These types of conflicting viewpoints can lead some clinicians or services to oppose a clinician’s decision to let go. Other clinicians may have trouble letting go, if they feel unable to manage the anxiety that comes via pushback from other health professionals. Clinicians can also experience a sense of guilt in leaving another professional to hold perceived risk. Under these circumstances, some clinicians continue to struggle with letting go of children, young people and their family/whānau.

6

Making case closing easier - processes for letting go Planning for letting go with children, young people and their family/whānau should begin from the first contact. By involving children, young people and their family/whānau in the letting go process from the outset, we increase their sense of control and reduce the culture of inter-dependency between service users and providers. For some children and young people, the therapeutic relationship can feel like one of the most consistent and stable relationships they have experienced, especially where the child or young person has experienced trauma in past relationships through losses, separations, or abandonment. Some children and young people may never have experienced a positive and mutual ending of a relationship before, for example, a loved one’s death would have been entirely out of their control and if not supported through a healing from grief process; be interpreted negatively. By engaging in letting go effectively from the start, the child or young person can instead be empowered to end the relationship through the process of choice. In doing so, this too can become part of their treatment and healing. Letting go can then become a positive and empowering experience for the child or young person and their family/whānau. Remember a key component of the CAPA philosophy is to ensure we offer children and young people and their family/whānau choice at every point. As an example, a choice is involved in the process of deciding whether to have another appointment or not.

This next section discusses processes that can assist with letting go.

Use care plans

The development of care plans is important, as care planning helps clinicians, the child/young person and family/whānau to be clear about what they are all aiming to achieve. A care plan is a description of the main issues, goals and intervention plan and also identifies which professionals and agencies will be involved as partners. Having care planning and SMART goals makes it easier to determine when to let go, as well as giving focus to the work. The use of outcome measures such as HoNOSCA / HONOS and feedback systems can help both clinicians and the child, young person and family/whānau review how things are going. Care plans also help ensure the expectations of all parties are matched, so that the child, young people, family/whānau and clinicians can work towards common goals.

7

Talk and plan endings from the beginning

Letting go should not be seen as the last stage of treatment (a discrete event); rather, letting go is a process that should be detailed and planned for from the first session. The time-limited nature of any treatment should be established from the very beginning and it is important to discuss the parameters around treatment as early as possible with the child, young person and family/whānau. Clinicians should ensure there are clearly defined review points throughout treatment; this allows for discussion regarding the child/young person’s progress, review of their achievements and consideration of the work that remains. Using routine outcome measures

8

Ideas for developing care plans include:

• As a team, agree the headings and format of care plans for your service

• Write in plain English, avoiding jargon

• State the Partnership clinician (key worker), co-workers, agencies and network

• Make goals SMART

• Record what the family/whānau and others will do

• Include dates for review

• Include baseline and regularly review outcome measures

• Ensure copies are made available to family/whānau and networks with consent

• Have a system for collating outcome measures so each clinician knows how their cases progress.

SMART goalsare specific, measurable, attainable,

relevantand timely

SMART goals

Health of the NationOutcome Scales

for Children and Adolescents

is for children and adolescents aged

3 to 18 years

HoNOSCA

Health of the Nation

Outcome Scales is a clinician

rated tool

HoNOS

8

9

can help with structuring these conversations with the child or young person and their family/whānau about how things are progressing, and open up conversations about moving forward. Clear, early, continued communication around the completion of treatment will help prepare the child/young person and family/whānau so the ending doesn’t appear sudden or arbitrary. The child, young person and whānau will instead be able to understand how treatment progresses, and these open conversations will assist with obtaining a better understanding of why letting go is necessary. Planning for letting go should include discussions about the range of other services available within the community, what these services can provide and how and when they can be accessed by the child or young person and their family/whānau. This again assists to provide choice to the family/whānau about when and how treatment ends.

Create realistic goals and expectations

Developing and agreeing on clear and achievable goals can assist with realistic expectations regarding the likely outcomes to be achieved when accessing ICAMHS support. Setting realistic goals can make the end of treatment a positive and empowering process for children, young people, their family/whānau and clinicians. When the goal envisaged is being achieved, the child or young person is likely to feel encouraged, more positive about themselves, their abilities, and ICAMHS. Realistic goals can also assist clinicians to view their work and themselves in a positive light.

It is important to discuss the different ways a good outcome might look, such as exhibiting reduced symptoms or feeling more able to cope or carry on with regular life. Depending on how treatment outcomes are measured, it may not be immediately obvious that a child or young person has made progress; making it all the more important to consider a range of measurements.

Many children and young people will continue to have difficulties after accessing ICAMHS, especially as some difficulties may be enduring. To ensure realistic goals can be set, conversations around the limitations of ICAMHS are important. Clinicians should be clear that the intervention may be more helpful for some children or young people than others, and that perfection is unachievable. The possibility of ongoing risks should also be addressed with the child, young person and family/whānau, so they can understand that risk-taking is necessary for healthy development, and that risk is dynamic and cannot be fully controlled.

9

Other sources of support

Alongside identifying, discussing and engaging other sources of support within the community, clinicians should work with children, young people and family/whānau to produce self-management, crisis, or relapse plans; sometimes referred to as ‘just in case’ plans. This can include identifying ‘back-up networks’ outside of ICAMHS that can provide support after letting go. Back up network members may include family/whānau, friends, and teachers. It may be appropriate to involve these people in some of the treatment reviews, so they are better prepared to offer support to the child or young person and family/whānau at the end of treatment. Clinicians should ensure the establishment of early communication with other services across sectors rather than waiting till the time of transition. This allows ample time for the other professionals to prepare and engage in the child or young person’s transition. Pre-empting the transition point is especially important when the young person is close to the age of transitioning into adult services.

Have a systematic approach to long-term issues

Some mental health concerns are recurrent or persistent in nature, requiring ICAMHS interventions that involve bursts of contact during acute periods followed by infrequent booster type contacts.

It is with this group that clinicians often feel stuck and worried that they cannot let go for fear the child or young person will not cope, or because they know the child or young person has an enduring problem. These children, young people and their family/whānau may continue to need help and support, but not necessarily with ICAMHS in a continuous way. The sooner ICAMHS clinicians engage effectively with other services, agencies, sectors and systems, the more appropriately and safely clinicians can let go of these children, young people and their family/whānau. Clinicians can start by asking what longer-term supports family/whānau, children and young people experiencing enduring problems may need. Agreements may be developed with partner agencies about types of longer-term support to be provided. It may be that in certain situations ICAMHS will provide opportunities for the child/young person to bypass waiting lists and re-enter the service sooner if necessary. Services may decide to offer ‘boosters’ or drop in group sessions to the child/young person once treatment formally ends. These opportunities and suggestions may help reduce anxieties around the changes associated with letting go when longer term problems remain present. While letting go should empower the child/young person to attempt to manage their mental health independently, there needs to be an opportunity to re-engage with ICAMHS in a timely way if required.

10

Clinicians supporting each other

Culture, management and leadership within services may also impact on the letting go process. Clinicians need to be able to have open discussions regarding concerns such as risk, and in doing so, avoid a ‘blame’ culture that can lead to clinicians holding on to families/whānau longer than clinically necessary.

Peer group and individual supervision and support are important. Clinicians can use these opportunities to discuss problems, receive advice on particularly complex situations and recognise that they are not alone in providing care. Supervision can also be a prompt to consider and review why longer duration case files remain open. These types of discussion forums with colleagues can provide a broader perspective of treatment, which may offer specific advice encouraging letting go.

Teams are encouraged to adopt a collaborative approach to multi-agency meetings and multi-disciplinary teams. Clinicians and professionals from other services must also establish realistic and matching expectations. This requires routine conversations about letting go throughout treatment, as well as regular review of the goals and discussions about ongoing risk. It is also important to increase mutual understanding around the constraints and capabilities of every service, which should subdue other professional anxieties and any potential pushback.

Other practice recommendations

The process of letting go should remain flexible, as it depends on the needs of the individual child or young person and their family/whānau; however, a more structured approach can be helpful for complex endings. Clinicians should work to develop a language that fosters hope and mutual trust in conversations around letting go and appropriate training and ongoing support should continue to be made available to support clinicians with the letting go process.

Tips for letting go:

• Plan and talk about letting go with the child/young person and their family/whānau from the first contact

• Care planning – with a view to letting go

• Make goals measurable, achievable and realistic so everyone is able to see clearly when the goals are achieved

• Agree on a set number of sessions or end date and review regularly using progress measures

11

• Have an alert system to remind you and the child, young person and their family/whānau to review goals with a view to letting go

• Discuss other sources of support regularly

• Involve other agencies early (including the referrer) to ensure appropriate transition planning and timely follow up when letting go

• Support each other as professionals both within and across agencies

• Look for alternatives to ICAMHS for those with enduring problems

Consider:

• Do you regularly discuss transitions and closing case files in team and individual supervision?

• What system is in place in the team to remember to review children and young people?

• Do you discuss how to involve other agencies if you have not already done so?

• Does your team have a common view on the amount of change needed before you let go of children, young people and their family/whānau?

• How does your team involve the child/young person, family/whānau and other agencies in the review process?

• Does your team actively discuss with every child/young person and family/whānau, right from the start, the time when they will no longer come to the service?

The CAPA activity of letting go refers to the ending of current contact with a child/young person and their family/whānau which involves a transition out of ICAMHS. CAPA is all about empowering children, young people and their family/whānau to access their own resources and the resources within their communities, so they can move forward with their lives. ICAMHS helps these children and young people to regain control of their lives. The focus is on the time the child, young person and their family/whānau will no longer need us rather than assuming the need for extensive ongoing ICAMHS input. Remember letting go should not be thought of as an ending, but a beginning - Certificates not tissues required…

12

ReferencesDalzell, K. Garland, L. Bear, H. Wolpert, M. (2018). In search of an ending: Managing treatment closure in challenging circumstances in child mental health services. London: CAMHS Press.

The Choice and Partnership Approach (CAPA). (2013). Retrieved from http://www.capa.co.uk/

werryworkforce.org